Yoga classes. Spirituality discussion groups. Smoking cessation programs. Sports teams. Anti-homophobia workshops. You may be asking yourself: "What do these things have to do with HIV prevention? And why do they matter for gay and bisexual men specifically?" The answer: These activities (and many others) are part of a growing "Gay Men's Health" movement that is starting to redefine the way we do HIV prevention and sexual health promotion with gay and bisexual men.

In the early 1980s, when HIV emerged as a major epidemic among men who have sex with men (MSM), gay men's communities, along with many allies, organized themselves to advocate for recognition from government and healthcare providers. They initiated an unprecedented cultural shift to change their sexual practices and stem the rising tide of HIV infections.1

More than a quarter of a century later, however, HIV incidence among gay and bisexual men across Canada is not decreasing. In 2008, the Public Health Agency of Canada estimated that as many as 47% of new HIV infections nationally continue to be identified among MSM.2 It is estimated that the HIV prevalence rate among MSM is approximately 50 times higher in five Canadian cities than it is among the general Canadian adult population.3

A Note on the Term "Gay and Bisexual Men"

Research on gay, bisexual, two-spirit and queer men and other men who have sex with men is extremely varied in terms of how these populations are defined, and therefore how they are reflected within the research.

Some studies, for instance, ask men to identify their sexual orientation (e.g. homosexual/gay/bisexual/two-spirit/straight), while others are behaviour-based and ask men whether they have ever had sex with another man, to determine sexual orientation. For a helpful discussion on these distinctions, click here.

For the purposes of this article, the term "gay and bisexual men" refers to men (cisgender or transgender) who share a common trait in that they interact with other men sexually and/or romantically. These men may or may not identify as gay, bisexual, queer, two-spirit, straight or otherwise.

Service providers and researchers increasingly recognize that to truly address and impact transmission rates of HIV and sexually transmitted infections (STIs) among gay and bisexual men, we must understand and address other mental, physical and social health challenges they face. This recognition reflects a growing movement to frame HIV prevention among gay and bisexual men in a way that acknowledges the broader context of their health and well-being rather than focusing exclusively on HIV status and safer sex practices.

How Does the Health of Gay, Bisexual, Queer and Two-Spirit Men Differ From That of Heterosexual Men?

A growing body of research is revealing that beyond HIV and STIs, there are a number of other health concerns that gay and bisexual men appear to be more affected by than their straight counterparts. Research (most of which has been done in urban settings) shows that gay and bisexual men often face:

These health concerns, which are not directly related to sexual activities between men, are likely a consequence of the stigma and discrimination faced by gay and bisexual men.23 Indeed, Statistics Canada has reported that one in 10 hate crimes is motivated by sexual orientation,24 and that approximately 44% of gay men and 41% of bisexual men have experienced some form of discrimination, compared to 14% of men who identify as heterosexual.25

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Gay and bisexual men's health problems are often not adequately addressed by healthcare providers.26 The 2004 Canadian Community Health Survey, for instance, revealed that men who identified as homosexual or bisexual were nearly twice as likely as men who identified as heterosexual to report an unmet healthcare need in the previous year.27 This is not surprising given the fact that in urban centres more than 20% of gay and bisexual men do not feel comfortable disclosing their sexual orientation to their family doctors.28,29 In rural and northern regions, this number increases to as much as 45% -- often due to fear of a breach of confidentiality or discomfort with openly discussing sexuality with their family doctors.30

It is also important to remember that the population of men who identify as gay and bisexual is extremely diverse. Therefore, many of the unique health concerns faced by men due to their sexual orientation or activities may be experienced differently according to their ethnoracial or cultural background, income, gender identity, citizenship status, age, ability, HIV status, languages spoken, and the many other social and cultural factors that can influence one's health.

Syndemics: Making the Links Between Gay Men's Health and HIV Prevention

While the unique health issues faced by gay men are cause for concern in and of themselves, an emerging area of research is showing that these multiple epidemics (such as depression, substance use, partner violence and HIV) also reinforce each other, and together lower the overall health of gay and bisexual men more than one epidemic might do on its own.31 This concept has been termed syndemics.

Syndemics research looks at the variety of health problems faced by gay and bisexual men and how their co-occurrence influences HIV risk. A body of research shows a linkage between poorer health conditions related to psychosocial challenges and high-risk sex (unprotected anal intercourse).32-34

The concept of syndemics also encourages an examination of resiliency and strength among gay and bisexual men. Not all gay and bisexual men who have experienced adversity develop syndemic conditions; even if they do, not all those who develop syndemic conditions engage in riskier sex practices. For example, one of the first studies on syndemics highlighted that among gay and bisexual men who experienced three or more psychosocial health problems, 77% had avoided engaging in high-risk sexual behaviours.35 This suggests that many gay and bisexual men have already developed successful health-promoting behaviours, and that understanding and encouraging these behaviours could be a useful strategy for future interventions.

The idea of syndemics raises a number of challenges for service providers working with gay and bisexual men. Firstly, it calls on service providers to recognize that HIV is not necessarily the sole -- or even the most important -- health challenge experienced by gay and bisexual men. Secondly, it suggests that for at least some gay and bisexual men, a truly effective strategy to prevent the transmission of HIV must also attempt to address other psychosocial problems they face.23 Thirdly, the idea of syndemics suggests that strength-based approaches, which build on the existing strengths and assets among gay and bisexual men and their communities, might be an important tool in the HIV prevention toolbox. Such approaches aim to encourage things such as pride, sexual creativity, social creativity, social activism, self-monitoring and social support.35

There is no "one-size-fits-all" approach to how service providers can integrate broader concepts of gay and bisexual men's health and HIV prevention. Such an integrative approach has been adopted in different ways by different organizations, depending on things such as: responsibility to meet funders' requirements, organizational capacity, alignment with values, and the unique local situations organizations work within.

Some organizations have elected to take on a broad "gay men's health" agenda whereby HIV and STIs are given special attention but are integrated with other health-related programs and services. In Montréal, for example, RÉZO (formerly known as Action Séro Zéro), which had originally focused more exclusively on HIV and sexual health, took on a broader mandate of health promotion with gay men that included, but was not limited to, HIV and STIs. A second example is the Vancouver-based Health Initiative for Men (HiM), which started out as a program within AIDS Vancouver and branched out to form its own gay men's health agency. These organizations address gay men's health in many different ways: through social events, discussion groups, individual support, sexual health services, and training in cultural competency for healthcare providers -- these are just a few examples. Check out their websites to get better sense of how the organizations address gay men's health in a more holistic way.

Other organizations that provide services to gay and bisexual men -- many of which are AIDS service organizations -- have integrated a broader understanding of gay men's health and syndemics into their programming in different ways:

Providing LGBT Sensitivity and Anti-Homophobia/Transphobia Workshops in Schools and With Healthcare Providers

Experiences of homophobia and heterosexism that can lead to psychosocial health problems often begin at early ages when young gay and bisexual men are still in school. Programs like T.E.A.C.H. (run by Planned Parenthood of Toronto) and G.R.I.S. Québec are good examples of how organizations are working to create safer environments for queer and trans youth.

Offering professional development opportunities for local healthcare providers can be an excellent way to create healthcare allies in your community. (For a resource you can use to help develop your own program, click here.36)

Building Strong Relationships With Partner Agencies and Enhancing Their Capacity to Work With Gay and Bisexual Men

Knowing which service providers are particularly welcoming to gay and bisexual men can help when thinking about where to refer clients who have needs that cannot be met by your organization.

Developing relationships with other agencies through meetings, ongoing communication, and partnerships, such as a local anti-homophobia network, can help bring awareness to the specific needs of gay and bisexual men.

Creating Social Opportunities for Gay and Bisexual Men to Connect

Social isolation can be a particularly difficult challenge for gay and bisexual men, especially in communities where other LGBT (lesbian/gay/bisexual/transgendered) people are not as visible. There are many ways that organizations can help provide gay and bisexual men with opportunities to connect, such as:

Social events, such as a gay night at a local bar/bingo hall/bowling alley/etc.

Participation in broader community events and showing visible support for LGBT communities with signs, flags, stickers, comments, etc.

CATIE and the Gay Men's Sexual Health Project

In January 2011, CATIE launched the Gay Men's Sexual Health Project, an exciting initiative to facilitate the creation of a national platform for service providers to share ideas, information, experiences and best practices. The project aims to address the particular HIV, sexual and other health needs of men who have sex with men, who identify as gay, bisexual, two-spirit, queer, straight, pansexual or otherwise. This project is informed by the report New directions in gay men's health and HIV prevention in Canada.

For more information about the Gay Men's Sexual Health Project, contact Len Tooley at ltooley@catie.ca.

Len Tooley is coordinator of the National Gay Men's Sexual Health Project at CATIE, which aims to facilitate pan-Canadian capacity building and knowledge translation among service providers working with gay/bi/queer/2-spirit men. He is also an HIV/AIDS and sexual health counsellor at the Hassle Free Clinic in Toronto, Ontario.

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